In the hope that I, may help others, I hereby make this anatomical
gift, if medically acceptable, to take effect upon my death. The words
and marks below indicate my desires.

I give
my eyes for the purpose of transplantation, medical research or education.
I further direct my next-of-kin herein named to execute this gift after
my death. I would like my next-of-kin notified of my pledge to donate.
Yes/No